[Necrosis in fingers and toes following local anaesthesia with adrenaline--an urban legend?].

Background: It is often maintained that a local anaesthetic (usually lidocaine) with adrenaline must not be used in fingers and toes because it may cause necrosis due to vascular spasm in end arteries. This review article is an attempt to find evidence to support this warning.

Method: Relevant literature was found by means of searches in PubMed limited downwards to 1946 and in EMBASE from 1980 to 2012, and in reference lists.

Results: Five review articles on finger necrosis following local anaesthesia concluded that lidocaine with adrenaline does not entail a risk of ischaemic injury. One article found 48 reported cases of finger necrosis in the period 1880 to 2000. Most were from the first half of the 1900s, and none involved lidocaine. Gangrene of part of the finger tip has subsequently been described in one patient with Raynaud's syndrome. No cases of necrosis have been described in a large number of reported accidents in which EpiPen injections contained the same quantity of adrenaline as is found in 60 ml lidocaine with adrenaline. Over a quarter of a million reports have been made of operations on feet, hands, fingers and toes anaesthetised with lidocaine with adrenaline without resulting necrosis.

Interpretation: There are no grounds for the warning against using lidocaine with adrenaline in fingers and toes. This anaesthetic offers considerable practical advantages. Care should be taken with infected fingers or fingers with poor circulation.